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HomeMy WebLinkAbout0219 GREEN DUNES DRIVE - HAZMAT alq &'een Cknwvi II -e_- ,q FI avtriF .e� to ae�I►ti Please.print:or type.(Form designed for use on elite(12-pitch)typewriter.) :COP C / Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number y+. 2.Page 1 of 3.Emergency'Response Phone 4.Manifest Tracking Number:. WASTE MANIFEST 4 -:�I� -�. Tl , 1 1 JJ K 5.Generators Name and Mailing'Addfdss Generator's Site Address(f different than mailing address) Ira i5�c Gen�la Phone:q, 6.Transporter 1 Compafiy Ida c U.S.EPA ID Number Ul 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address M=I *'` Waste ste Sca-ice hr U.S.EPA ID Number G , 781-935-9%, 6 Facility's Phone: ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit " 13.Waste Codes HM• 'and Packing Group(if any)) No. Type Quantity WtJVol. o INA1993, Con,bus6ble- LiclWd, N.O.S., _` dixed 001 T T r -are W i-'-�ts'oleum f_3��0. f':J bu.e s`b°eT icy_ �t"4 z 2. - W c� 3. 4.` 14.Special Handling Instructions and Additional Information owle4e this ed has nc t been aui>ied WI PCF's of hazardeus waste at-defined . ERG a #128 --1 o the vest f,f 2<ae generator'F i t 15. GENERATOR'S/OFF,EROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately describes above by the propeishipping name,grd.are classified„packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If expott.stiipment and l am the Primary r Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity genbrator)is true. r Ge } _ r� Month atu�9nA N rsOff=corsnrrielTypedame Day Year y J 16.International Shipments .;�--�' - - -- °• - F- ❑Import to U.S. ❑Export from U.S., Port of entry/exit Z Transporter signature(for exports only): Date leaving U.S.: w 17.TransporterAcknowledgment of Receipt of Material§ : Transporier.l Printed/Typed Name Signature Month Day. Year IL Txr<ts;m..:Gx>3: t Alf` - �� QTransporter 2 Printedrryped Name ' "' `" Signature Month` Day► Year tr t- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity El Type El Residue ❑Partial Rejection El Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number ra Facility's Phone: w 18c.Signature of Altemate Facility(or Generator) Month Day Year Q z S19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. / 2. 3. 4. N 20.Designated Facility Owner or Operator.Cepffcffc�tion of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printedf Typed Name j. Signature Month. Day Year . �. {J'7 I f_5 /�L EPA Form 8700-22-(Rev.3-05Previous eifions are obsolete. _ _ DESIGNATED FACILITY TO:GENERATOR 20/ Lf l 5-00 9/3 /�'Io.v. y/: o 3/3///44 A y 4401Z� The Commonwealth of Massachusetts it 4 y, 1�I ow Department of Public Safety lL 527E rm 4.00 Application for Permit, Permit, and Certificate of Completion for the Installation or Alteration of urning Equipment and the Storage of Fuel Oil tenter vill,,,Osterville, Marstons.Mills r fZ z / (City or Town) (Date) 01920 Permit #s: F 3 Elec. FDID #: . - r Yee Paid: $,?5 _ Owner/Occupant Name: Tel.#: Installation Address: Serviced Floor or Unit #: ❑Heating Unit ❑Domestic Water Heater ❑Power Vent ❑Other Burner: ❑New. p Existing ❑Location: Trade Name: Mfg: .Type: Model# or Size: Nozzle Size: . ❑Fuel Oil ❑Kerosene ❑Waste Oil Storage Tank: ❑New ❑Existing Location: ' } i.J h• Type: 6W,4U>V� Capacity: o p gallons No. of Tanks: Special,requirements (or additional safety devices) �AA1�/9-M C- Z-ey } U ❑OSV Valve ❑Oil Line Protected ❑Sheet Rock ❑Sprinkler AFUE: ❑yes Lino EF:El yes ❑no (Furnace and Boilers) (Water`heater-) Co. Name: 3G i✓v 6SAP t + - Tel # �-01 city: -36� oPP& Address: :'. _�Q%rox �9s' ci ;� � ��"�, Zip; De'' Completion Date: Combustion Test: GrosZt mp.: Net Stag: 2eech Draft: ; Smoke: Overfire Dr , Efficien sting %: t. I, the undersigned certify that the installation of fuel burning equipment has been made in accordance with M.G.L. c. 148 and 527 CMR 4:00 currently in effect. Furthermore, this installation has been tested in accordance with such requirements, is now in proper operating condition and complete instructions as to its use and maintenance have been furnished to the person.for whom the installation (or alterati was made: Installer J �-�CC GS 49Ai,� `O ZgSZ� Print Name Cert of Comp. # Signature(no mp) Address: jy ity:.. Once sy the fir t, this is a PE r the storage and u e.of oil bu iii equipment. Approved Date: REFER T CHECKLIST ON REVERSE SIDE Form Distribution:White: Fire Dept. (Application) Yellow: Installation(Permit To Store) Pink: Installer.(Permit To Install) . This form approved by the State Fire Marshal and provided courtesy of the Mass.Oa Heat Council. Form design In NCR by Cotuit and COMM Fire Depts., July 1,1..996 PERMIT EXPIRES 60 DAYS AFTER ISSUE DATE. r °Ft"E T Town of Barnstable ti Regulatory Services Barnstable BARNSTABLE, ` Richard V. Scali Director 9`b MASS. Public Health Division I I AtFD N10`1 A Thomas McKean, Director zoos 200 Main Street Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 March 30,2015 LESLIE,BONITA 226 MAIN ST CENTERVILLE, MA 02632 RE: Underground Storage Tank 219 GREEN DUNES DRIVE Centerville Map/Parcel: 245024 Tank Number: 1 Tag Number: 00943 Board of Health records indicate that an underground fuel(or chemical) storage tank at the above location exceeds thirty(30)years in age and has not yet been removed as required by the Town of Barnstable Code Chapter 326, Section 3, Fuel and Chemical Storage Tanks. You are directed to remove this tank within sixty(60)days from the date of this Notice. Upon completion of the tank removal and within ninety(90) days of receipt of this Notice,please submit to this office a copy of the permit for storage tank removal issued by your local Fire Department. This permit is required to he obtained prior to the tank removal. This copy of the removal permit serves as documentation that the underground storage tank was properly removed and disposed of. Should you be unaware of the existence of the above mentioned tank or its possible previous removal, an independent third party(i.e. oil company,tank removal company, or environmental services company) may be able to assist you in physically locating and/or verifying the current existence of the tank. Should this be the case, a written document from the independent third party is required within ninety (90)days of receipt of this notice as verification that the tank had been previously removed and/or does not exist. You may request a hearing before the Board provided that a written petition requesting same is received by the Board of Health within ten(10)days after this order is served. Failure to comply with an order of the Board of Health will result in automatic scheduling of a hearing before the Board at the July 14,2015 public meeting. The meeting will begin at 3:00 PM and will be located at Barnstable Town Hall,367 Main Street,Hyannis,MA 02601. Thomas A. McKean, RS, CHO Public Health Division, Director Q:\Hazmat\Underground Tanks\2015\letters\30 yr old UST 219 Green Dunes Dr CENT.doc I V TOWN OF BARNSTABLE — UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION MAP N0. � PARCEL N0. ADDRESS OF TANK: r4l IF Al j,'1)14i�S l y,' V I L L A G E Number ftrdwiet MAILING ADDRESS ( IF DIFFERENT FROM ABOVE) : !. OWNER NAME: / 1. Y l C 1 I ~~ % 1 AI 1t,/i ' PHONE: 7t76' /0 2 4 INSTALLATION DATE: �fl �,' -` BY� _ 1 *NISTALLER ADDRESS: �R �`- � ' CERT.NO. TANK L 0 C A T ION �e-uw> V Y (DK=CR I=K TANK�LG"C9T I ON W I" H PIeBf�KC'rot au Z LD 2 NO> CAPACITY 19fi944kTYPE_OF TANK AGES YRS. FUEL/CHEMI-CAL ' � TE�NG,a CERT'IF I CATION [ J PASS [ J FAIL DATE LEAK DETECTION [ ] CHECK__ IF N/A TYPE%BRAND A rl, ­ _\ 4, ZONE OF CONTR I BUT I ON [ ~] YES [ ] N0--�' DATE TO �BE-REMOVED - /\q FIRE DEPT PERMIT ISSUED [X] YES [ ] MO DATE,; � �' / `? CONSERVATION [ ] CHECK IF N/A DATE BOARD OF HEALTH TAG NO. [ J DATE PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD - J F2©k7- IC i� } d .'i �1y �i ,��• t trn 4 ':r$'S€ `% $ ,CENTERVILLE OSTERVILLE .FIRB DEPARTMENT K 7T PERMIT .FOR :STORAGE OF 'FU•EL OIL. �� t I� .Yy k y In accordance with provisions of Chapter 148, () L,;and Reg ul>ttions` made under authority •hereof r 0Y •e .rr - K�tiv .,. Name 1;... l.5...l1)r... e s ,'E f (owner or occupant) t -'(Installer) PI ;Address Q X e.�Xl...DvrxeS...�X:: dress 5:: r.y..:;DU 3/ann r• Burner Storage' *; r ABC........................... . Type of Tank F.X i 3ta ng.: E..�.., Manufatturer r...�� ... X A3CAx ... gals. or Size...........rppacit >u _ 9 �. r� ,i}rleAOdel+Na.•}or SIZ@ ... LOCQtIon, .�.indergY'f7►untj..............: ' Type gun............: .:Mass. Approval No 1Q851 *, a g3 J`.M.Farringtbn r 'u Perna IssuRd .'.�.ta:.. ... .3:, .. (Head of Fire Departments ; c�2 T' �• • ••••.•••••••••••••••••••.• ,fF • •• t 1.� n. s SSSS „y ` ry 4 By.'. r�a'A ' t �( ro ..... .....s:.1+, ... w wtar (THIS PERMIT MUST BE CONSPIC�IOUSLY,POSTED:UPON THE.PREMISES) '� �I.9.•